© Springer Nature Singapore Pte Ltd. 2017
Saravana Kumar and Rachel Maria Gomes (eds.)Bariatric Surgical Practice Guide10.1007/978-981-10-2705-5_99. Technical Considerations of Laparoscopic Gastric Plication with or Without a Band
Chih-Kun Huang1 , Abhishek Katakwar2 , Jasmeet Singh Ahluwalia3 , Vijayraj Gohil4 , Chia-Chia Liu1 and Ming-Che Hsin1
(1)
Body Science & Metabolic Disorders International (B.M.I) Medical Center, China Medical University Hospital, Taichung, Taiwan
(2)
Bariatric and Metabolic Surgery Centre, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, Telangana, India
(3)
Global Hospital, Jalandhar, Punjab, India
(4)
Asia-Prio Bariatric and Metabolic Surgery Center, Oasis International Hospital, Chaoyang District, Beijing, China
9.1 Introduction
Successful weight loss and resolution of comorbidities, coupled with improved minimally invasive procedures, has accounted for the recent rise in the number of bariatric surgeries worldwide [1]. Laparoscopic adjustable gastric banding (LAGB) qualifies as a safe and reversible procedure with a percentage of excess weight loss of % EWL of 50 % at the end of 3 years. However, if patients do not have good compliance and there is a diet modification leading to intake of calorie-dense liquids, only 40–60 % of these patients are able to maintain acceptable long-term weight loss [2–6]. Other, band complications such as erosion, infection, and slippage are believed to be associated with frequent adjustments, though adjustments are the most important factor affecting weight loss and unfavorable long-term outcomes [2]. The last decade has seen rise in the popularity of laparoscopic sleeve gastrectomy (LSG) and has shown promise in mid-term results [7]. However, this procedure has the longest staple line among all bariatric procedures which gives rise to the concerns of staple line leak, bleeding and stricture. Furthermore, post-operative decrease in lower esophageal sphincter pressure has been observed [8]. Another gold stand procedure is roux-en-Y gastric bypass which carries the paradox of excellent weight loss but long-term vitamin deficiency [9, 10].
Talebpour and Amoli introduced the concept of plication of the greater curvature without cutting the stomach and published their 12-year results with acceptable outcomes [11]. Specifically, gastric plication does not involve gastric resection, intestinal bypass, or placement of a foreign body, and this could potentially provide a lower risk alternative that will appeal to patients and referring physicians. The rationale for this procedure addresses issues that might limit the acceptance of other bariatric procedures.
LAGB can be combined with plication. Referred to as the laparoscopic adjustable gastric banded plication (LAGBP); invented by Chih-Kun Huang, it has been recently reported as a novel bariatric procedure with good 4-year results [12]. Here in, we describe laparoscopic gastric plication (LGP) as a standalone surgical technique as well as LAGBP.
9.2 Laparoscopic Gastric Plication
The operation involves mobilizing the greater curvature of the stomach, similar to the dissection for sleeve gastrectomy, and infolding or imbricating the stomach to achieve gastric restriction. Increasing number of LGP procedures are being performed worldwide, and this operation is being marketed as a new option for surgical weight loss by some practices.
In 2011, American Society for Metabolic and Bariatric Surgery issued recommendations regarding gastric plication for the treatment of obesity [13]:
- 1.
Gastric plication procedures should be considered investigational at present. This procedure should be performed under a study protocol with third-party oversight (local or regional ethics committee, institutional review board, data monitoring and safety board, or equivalent authority) to ensure continuous evaluation of patient safety and to review adverse events and outcomes.
- 2.
Reporting of short- and long-term safety and efficacy outcomes in the medical literature is strongly encouraged. Data for these procedures should also be reported to a program’s center of excellence database.
9.2.1 Surgical Technique
All patients should receive prophylaxis against deep vein thrombosis and antibiotics as per the policy of the hospital before starting the procedure. A bariatric operating table providing at least 45° of reverse Trendelenburg position is preferable.
Room Setup:
Patient lies supine on the table with arms extended. Patient must be fastened to the table to prevent slippage during change of posture. Adequate padding must be ensured. Surgeon stands on the right side, camera-surgeon and first assistant on the left side of the patient.
Port placement:
Four or five ports are used. Pneumo-peritoneum is created using veress needle. Surgeon’s left hand port in right upper quadrant (5 mm) and right hand at supraumbilicus (15 mm). 5 mm assistant port is in left upper quadrant.
Liver retraction:
The left lobe of liver could be retracted by Nathanson liver retractor or elevated using T-shaped liver suspension technique [14].
Mobilisation of greater curvature:
The junction of right and left gastro-epiploic vessels is seen and greater omentum is divided close to the stomach above this point till left crus of diaphragm is clearly seen. Below this point, the omentum is divided distally but preserving right gastro-epiploic vessels thereby maintaining arterial supply and venous drainage of plicated stomach. This helps in decreasing edema of the stomach wall. Dissection is carried out distally till 3 cm from the pylorus.
Gastric plication formula:
Stomach is measured transversely at the level of 6 cm below gastroesophageal junction (“x” cm) and plication formula is applied to determine the amount of plication (y = (x + 1)/2). Stomach is marked from lesser curvature side “y” cm away.
Plication:
It is started from 0.5 cm from esophago-cardiac junction and progresses till 3 cm from pylorus. The greater curvature is inverted interruptedly using non-absorbable sutures (2–0 Ethibond Excel Ethicon, St. Stevens-Woluwe, Belgium) at every 2 cm and is then reinforced with a continuous seromuscular suture (polypropylene 2–0). Continuous second layer is important in preventing herniation of inverted stomach out of the first layer.
9.2.2 Postoperative Management
Cefazolin (1 g every 8 h), Pantoprazole (40 mg every 24 h), and Dexamethasone (5 mg every 8 h) are intravenously administered to the patients for 1–2 days postoperatively. Moreover, we add serotonin receptor antagonist, Navoban (Sandoz Pharma Ltd, Basel, Switzerland), to alleviate obvious nausea and/or vomiting in the immediate postoperative period. Patients are given oral sips of water 4–6 h after the surgery. Patients are discharged if there is no vomiting and they are able to drink enough liquids. Oral PPIs are given for 1–3 months following surgery. Liquid diet is prescribed for the first week followed by pureed diet for the second week. This is followed by semi-solid diet for another 2 weeks after which solid food is introduced in a stepwise fashion. During the first year, all patients are prescribed multivitamins and iron supplements. Follow-up visits are scheduled every 3 months. Full evaluation of patient including upper gastrointestinal endoscopy is performed after 1 year for surveillance and yearly thereafter.
9.2.3 Results
LGP appears to be an effective operation for the treatment of morbid obesity. In the systemic review of 521 patients of prospective studies, the rate of reported complications reached 15.1 % and reoperation rate was 3 % [15]. Minor complications were at a rate of 10.7 %, with nausea, vomiting, and sialorrhea being the most common in 5.7 %, intraoperative bleeding which was managed without the need for conversion or transfusions in 1.7 %, and dysphagia or obstruction which was successfully managed conservatively in 2.6 %. Major complications presented at a rate of 4.4 %. Major complications that required reoperation were at a rate of 3 %, the most common causes being gastric obstruction (due to fold prolapse, fold edema, adhesions, or accumulation of fluid within the gastric fold) in 1.5 %, leaks due to suture line disruption and herniation in 0.7 %, and gastric fistula in 0.1 %. No worsening of GERD symptoms or new GERD onset was reported.
Another systematic review yielded 14 studies encompassing 1450 LGP procedures. The mean preoperative body mass index (BMI) ranged from 31.2 to 44.5 kg/m2, and 80.8 % of the patients were female. Operative time ranged from 50 to 117.9 min (average 79.2 min). Hospital stay varied from 0.75 to 5 days (average 2.4 days). The percentage of excessive weight loss (% EWL) for LGP varied from 31.8 to 74.4 % with follow-up from 6 to 24 months. No mortality was reported in these studies and the rate of major complications requiring reoperation ranged from 0 to 15.4 % (average 3.7 %) [16].
Related posts:
Selection of Bariatric Surgery Procedures in Special Circumstances
Gastroesophageal Reflux and Bariatric Surgery
Perioperative Management of Medical Comorbidities After Bariatric Surgery
Management of Leaks After Sleeve Gastrectomy
Management of Leaks After Gastric Bypass
Importance of Protein After Bariatric Surgery
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
